Pilot implementation of the national longitudinal communication curriculum: experiences from four German faculties

Background: The German national longitudinal communication curriculum provides medical faculties with orientation for the content of their communication teaching. But its implementation also requires changes in the organization of teaching. However, due to a lack of reports and studies on experiences with the development and implementation of communication curricula, recommendations on the procedure and the use of suitable instruments cannot be provided. Consequently, as part of this exploratory study the implementation process of the communication curricula was observed at four faculties. Methods: A comparative case study was conducted against the background of a change management concept. The four participating faculties were selected in such a way that they differed significantly in their initial conditions, particularly the development stage of the communication curriculum. Group interviews were conducted with the project teams at each faculty concerning the conditions and experiences with the implementation process. The evaluation took the form of a qualitative content analysis with a focus on identifying supporting and inhibiting factors and useful activities. Results: Different faculty approaches, support structures, core skills, the scope of study and examination regulations, teaching organization and available resources can have a major impact on the implementation processes. It became clear that, depending on the status of the implementation process, other barriers and supporting conditions gain in importance. Strategically, it proved to be a particular success factor to implement the communication curriculum together with other innovations in the course of the conversion to a model study program. This enabled a particularly quick and efficient implementation. The implementation into an existing curriculum proved to be much more protracted. In addition, a change management concept was used to illustrate which measures were found to be effective for which task areas. This includes, for example, curricular mapping, the development of skills in communication teaching or the integration of communication into exams. Conclusions: Thus a concept with strategies and measures for the implementation of the National Longitudinal Communication Curriculum is available. It already contains numerous suggestions for planning one's own approach in line with the conditions and resources of other locations. However, it needs to be supplemented and further validated.

implement the communication curriculum together with other innovations in the course of the conversion to a model study program. This enabled a particularly quick and efficient implementation. The imple-  Own illustration according to Silverman [22].

Introduction
• the number of courses with communication-related content • the semester in which the course is to be taken • the learning objectives covered • the assignment of the course to the subjects.
In addition to these quantitatively determined variables, consultation was held with the project managers at the locations to determine, • whether there is a coordinated longitudinal curriculum with TU based on each other, • the extent to which communication is integrated into subject instruction, • whether there is a coherent approach to communication testing.
All four faculties had at least several individual courses in the first academic years and over the entire period of study (without PY) (see table 2), i.e. they were at least at level 2 or 3. Assignment to level 4 requires a longitudinal concept and the integration of communication-related content into clinical teaching. Such a concept existed only at site D. With regard to level 5, the learning objectives defined in the NKLM/sample curriculum were considered. Only Faculty D covered these to a large extent. Examinations with communication content existed at all particip-ating faculties, but there was no coordinated overall concept integrated into the subjects. Based on this data, a preliminary assignment of the curricula to the maturity levels was made and coordinated with the project managers at the locations. The result is shown on the left side of figure 1. The survey was repeated at the beginning of 2018 at the four participating faculties. It showed that in the meantime the level of maturity increased by at least one level in all four faculties, and by three in one of them. This can be seen on the right side of figure 1.

Survey and analysis methods
With this result in mind, those responsible for the project at the faculties were asked about their approach and experiences up to 2018. It was determined specifically for each location how the development of the communication curriculum had proceeded so far and which factors had favored the implementation and which had possibly delayed it. For this purpose, a group discussion of one hour duration was conducted at each participating faculty [30], [31]. In addition to two interviewers, the project managers and team members took part. They were two people in Faculty A, two people in Faculty C, five people in Faculty B, and two people in Faculty D.  (see table 1), participants were asked to indicate how they had been implemented so far and what had helped them. The discussions were recorded and then subjected by the two interviewers to a structuring content analysis [32], separated according to promoting and inhibiting conditions as well as goal-oriented activities. The statements were paraphrased and grouped according to similarity. This resulted in six categories of promoting and inhibiting factors. Likewise, the mentioned activities were assigned to each of the eight steps, redundancies eliminated, and similar contents grouped into generic terms. After the categories had been defined, the text passages were reassigned to the categories by one of the interviewers and another person who had not previously been involved in the evaluation process, with the aim of reliability testing. The evaluator agreement is 83.9% for the institutional framework and 85.3% for the goal-oriented activities.

Promoting and inhibiting conditions in the implementation process
The comparison of the faculties in terms of promoting and inhibiting conditions revealed considerable similarities in content at similar levels of maturity, so that faculties A and C as well as B and D were combined (see table 3). The faculty members' attitudes towards communication teaching were described as an influential factor with immense significance. If the majority considered communication to be of low importance, this was considered a major obstacle at low levels of maturity. But conflicts of interest and attitudes against more communication instruction were also reported at high levels of maturity.
If the degree of maturity is low, the support of the teams by the faculty management, the teaching coordinators of the individual subjects, and committed students is particularly critical for success. With a high degree of maturity this kind of support is given, but must be secured again and again, e.g. because central persons migrate.
The skills available at the faculty for communication teaching increase with the degree of maturity. At the beginning, there were only a few lecturers qualified to do so. They, however, contributed decisively to implementation. At a higher level of maturity, targeted competence development was reported through ongoing training, support for MME students, and the expansion of teachinglearning research. Another success factor was seen in the integration of communication teaching into quality management and teaching evaluation. The continuous student feedback increases competence in the field of communication throughout the faculty. Regardless of the degree of maturity, the study and examination regulations are often seen as an obstacle because they contain little room for innovation, especially for new types of examinations. The decentralized teaching organization, in which the individual departments are responsible for the implementation of communication teaching independently of each other, is also perceived as an impeding factor.

Goal-oriented activities within the framework of change management
The first analysis of the measures and activities for the implementation of the curriculum showed that if the maturity level of the communication curriculum was low, steps 1-6 were most often worked on, while steps 7 and 8 were worked on if the level of maturity was high. Table  4 shows those activities that have proven successful from the perspective of the interviewees. In the first step, "Establishing a sense of urgency", the opportunity of referring to educational policy develop- Table 3: Promoting and inhibiting conditions in faculties with low and high maturity of the communication curriculum Table 4: Proven activities and measures, assigned to the stages of change management ments to promote the communication skills of prospective doctors and the discrepancy with the status quo at the faculty was considered particularly helpful. The systematic inventory of the teaching content on communication, the curricular mapping, which shows gaps and redundancies, proved to be extremely helpful in this respect. For the second step, "Creating the guiding coalition", it was emphasized how difficult it was to recruit influential members of the faculty management for the implement-ation team at the beginning. The significance of this was particularly evident where support was promised but not provided through active involvement. Equally important was establishing a good internal network, as it helps new projects experience greater acceptance and makes upcoming planning and coordination processes easier to manage.
Step 3 refers to the vision and strategy. The most important result is that the overall strategy is of crucial importance. It makes a big difference whether the communication curriculum is inserted into an existing curriculum or is integrated as part of a more extensive redesign of the program. The enormous leap in the maturity of the communication curriculum of Faculty B can be attributed primarily to the fundamentally different strategic approach. There, a model academic program was developed in which the communication curriculum was planned from the beginning and implemented together with other changes.
The implementation into an existing curriculum during ongoing operations is more complex and time-consuming. In this case, a step-by-step approach is required, in which the initial curricular mapping was considered particularly helpful. In addition to gaps and redundancies in the content, it provided information about horizontal and vertical integration and coherence: Is the communication topic being dealt with simultaneously in courses of different subjects and is this coordinated in a meaningful way? Do the contents and methods build on each other over the course of the academic program? Is what is taught also tested? A particular difficulty was that the departments do not know what communication content is taught by whom and how. This results in redundancies and inconsistencies, for example different terminology and the lack of a longitudinal system, so that extensive coordination processes are necessary. A centralized teaching organization, e.g. with a platform on which information about courses is brought together, was considered a very valuable tool for coordination. A particular difficulty was that the departments do not know from each other which communication content is taught by whom and how. The consequences are redundancies and inconsistencies, for example different terminology and the lack of a longitudinal system, so that extensive coordination processes are necessary. A central teaching organization, e.g. with a learning platform, through which information about courses etc. is brought together, was seen as a very valuable tool for coordination.
Communicating the vision of change (step 4) and soliciting acceptance, the arguments listed in the table have proven helpful. In later phases of the implementation process, it is advisable to seek a broader public to raise awareness of the topic at the university and beyond.
To create a broad implementation basis (step 5) the qualification of the teaching staff is the central task. In view of limited resources, the possibility of standardized, certified training of student tutors was considered highly efficient (see [33], [34]). The participation of an increasing number of people in the process requires the establishment of structures, e.g. regular meetings or access to best practice examples, such as the toolbox, a moderated platform on which tutors can exchange teaching and testing examples [35]. The lack of simulation persons was highlighted as a particularly significant obstacle to the realization of competence-oriented teaching. Since they allow for practice in practical learning scenarios as well as the implementation of realistic exams, the creation of a pool of actors was considered absolutely necessary in order to implement communication theory according to the current state of knowledge.
The generation of short-term wins (step 6) is provided, for example, by pilot events that are announced, evaluated, and published throughout the faculty. The presentation of progress in communication theory at the faculty and the public recognition of good examples were also mentioned here.
Steps 7 and 8, consolidation and anchoring in culture, were combined because no group interview explicitly described specific measures for anchoring communication or medical conversation in culture. The inclusion of communication examinations in the faculty's examination plan was mentioned as an essential step towards consolidation. The faculties with a higher degree of maturity emphasized that a curriculum is never really "finished". Continuous adjustments to new developments are necessary. Triggers can be external requirements, but also the results of internal quality management and evaluation, which give rise to permanent improvements. As a result, the scope and complexity of the curriculum increases, making it necessary to fill long-term positions for coordination.

Discussion and conclusions
Progress in the maturity of the communication curriculum was noted in all four participating faculties. Faculty B stands out in particular, which, starting from multiple individual courses, has achieved an integrated curriculum with exams in a period of 3-4 years. The longitudinal and interdisciplinary integration of the curriculum was described as particularly challenging across faculties (Level 4 in figure 1). The task consists of locating the individual teaching units on communication in the subject courses and at the same time distributing them over the entire academic program in such a way that they meaningfully build on each other. This step involves a great deal of organization and coordination. The following measures proved to be particularly successful in this process: • Curricular Mapping, with its various functions for attitude change and strategy development [36], [37] • Competence development: training of lecturers and of student tutors and their integration into teaching [33], [34] • Faculty-internal networking to facilitate cooperation and coordination.
For advanced levels of maturity, the focus is on consolidation. The following points were considered to be particularly helpful in this respect: • Integration into examination plan/examination regulations, because: assessment drives learning [38], [39] • Integration of communication teaching into teaching evaluation and quality management as the basis for continuous adaptation and improvement • Teaching-learning research to develop further specific expertise.
All in all, the results provide a multifaceted picture of the conditions, activities, and measures that can be of importance in the course of an implementation process. As we have seen, each faculty has its own prerequisites that determine its own approach. Nevertheless, some crossfaculty success factors and obstacles could be identified, but with the caveat that the study is based on only four faculties and that only few people could be interviewed about the steps and aspects of the implementation. Nevertheless, a whole range of starting points for possible support programs emerged, some of which are relevant at different points in the process. As part of the further support of the faculties in their implementation process

Funding
The study is part of the project "Communicative Competencies of Physicians -Pilot Implementation, Accompanying Evaluation, and Development of Implementation Strategies for a Longitudinal Model Curriculum Communication in Medicine", which was funded by the German Federal Ministry of Health (funding code: ZMV I1 2516FSB200).